Management of Common Symptoms in Terminally Ill Patients

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Management of Common Symptoms in Terminally Ill
Patients

• Junior Rotation in Hospice and Palliative Care

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Symptom Prevalence(Cancer, AIDS, many other
terminal conditions)

• Fatigue
• Anorexia
• Pain
• Nausea
• Constipation
• Altered mental states (delirium)
• Dyspnea

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General Approach to Symptom Management at
End-of-Life

• Search for cause of symptom
• History, physical, laboratory (as appropriate)
• Treat underlying cause (if reasonable)
• Treat the symptom
• Re-evaluate frequently

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Fatigue
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Fatigue

• Most common symptom in medicine
• Lack of energy, tiredness
• Subjective weakness
• Diminished mental capacity
• Not relieved by rest
• May be incapacitating

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Diagnosis of Fatigue

• Often under diagnosed or ignored
• Multidimensional assessment tools available
• The Brief Fatigue Inventory (BFI)http//prg.mdand
  erson.org/bfi.pdf

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Pathogenesis of Fatigue

• Physical causes
• Decreased O2 carrying capacity
• Anemia or CHF
• Cancer, chronic illnesses
• Treatments for cancer, HBP, other
• Psychological causes
• Anxiety and / or depression

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Erythropoietin and Fatigue in Terminal Illness

• May benefit selected patients
• Symptomatic anemia
• Low erythropoietin levels
• Considerations
• Cost
• Time to effect (4 to 6 weeks)

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Palliative treatment of Fatigue

• Nonpharmacologic therapy
• Patient/family education Permission to be tired
• Energy conservation strategies
• Pharmacologic therapy
• Dexamethasone 2-20 mg qAM
• Methylphenidate 2.5-5 mg qAM and noon
• Antidepressant trial (SSRI)

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Anorexia and Cachexia
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Anorexia and Cachexia in the end-of-life setting

• Wasting syndromes
• Anorexia, weight loss, fatigue
• Cancer, chronic organ failure, chronic
  infections, AIDS.
• Treatable causes
• Chronic pain
• Mouth conditions (dryness, mucositis, thrush,
  HSV)
• GI motility problems (e.g., constipation)
• Reflux esophagitis
• Treatments for cancer

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Management of Anorexia and Cachexia, contd

• Hyperalimentation in cancer anorexia / cachexia
  syndromes
• Increase in body fat, not protein
• Potential for harm fluid overload, infections,
  aspiration
• Invasive
• Weigh benefit vs. burden

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Comfort Care for Terminally Ill Patients The
Appropriate Use of Nutrition and Hydration.RM
McCann, WJ Hall, A Groth-Juncker. JAMA 1994 272
1263-6.

• Patients generally did not experience hunger.
  Those who did needed only small amounts of food
  for alleviation.
• Thirst and dry mouth were relieved by mouth care
  and sips of liquid far less than needed to
  prevent dehydration.
• Food and fluid administration beyond the specific
  requests of patients may play a minimal role in
  providing comfort to terminally ill patients.

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Management of Anorexia and Cachexia

• Nonpharmacological therapy
• Patient and family education
• ineffectiveness and discomfort of forced
  feeding/nutrition/hydration
• Replace caregiver need to feed with behaviors
  that alleviate symptoms
• Eliminate dietary restrictions eat p.r.n., in
  amount desired
• Reduce portion size, more frequent meals

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Management of Anorexia and Cachexia

• Pharmacologic therapy
• Dexamethasone 2 to 20 mg po qAM.
• Megesterol (Megace), 200 mg po q6-8 hrs, titrated
  to achieve desired effect.
• Dronabinol (Marinol) 2.5 mg po BID or TID
  titrate dose to patient tolerance and desired
  effect.
• Androgens currently under investigation.

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Nausea and Vomiting
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Nausea and Vomiting

• Frequency in terminal cancer
• Nausea--50 to 60 of patients
• Vomiting--30 of patients
• Can be controlled in 90 of cases

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Nausea and Vomiting key organs involved

• Brain
• Chemoreceptor trigger zone (CTZ)
• Cerebral cortex
• Vestibular apparatus
• Vomiting center
• Gastrointestinal tract

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Nausea and Vomiting neurotransmitters involved

• Serotonin
• Dopamine
• Acetylcholine
• Histamine

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Pathophysiology Nausea and Vomiting
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Nausea and VomitingSome treatable causes

• Chemoreceptor Trigger Zone
• Drugs
• Metabolic e.g., renal, liver, electrolyte
  hyponatremia, hypercalcemia
• Cortical
• Anticipatory nausea
• Learned responses
• Anxiety, uncontrolled pain

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Nausea and VomitingMore treatable causes

• Vestibular
• Opioids trigger Ach-mediated nausea in vestibular
  apparatus
• Gastrointestinal Tract
• Gastritis/esophagitis
• Constipation, impaction
• Obstruction
• Drugs
• Tube feedings

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Management of Nausea and Vomiting
Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Management of Nausea and Vomiting
Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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M-Esis the 11 Ms

• Metastases
• Meningeal irritation
• Movement
• Mental anxiety
• Medications
• Mucosal irritation

• Mechanical obstruction
• Motility
• Metabolic
• Microbes
• Myocardial

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Management of Nausea and Vomiting
Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Persistent nausea...in a terminally ill patient

• Start with
• Haloperidol 1 mg PO or SC bid or tid, increase to
  10 to 15 mg/day, as needed
• If needed, add
• Antihistamine (e.g., hydroxyzine) and /or
• Metoclopramide (beware in bowel obstruction)
• Other Ondansetron (Zofran), Granisitron
  (Kytril), Dolasetron (Anzemet),
  methotrimeprazine (Levoprome), Aprepitant (Emend)
  - 300/dose

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Constipation, Bowel Obstruction
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Factors Affecting Bowel Movement

• Intestinal solids
• Stool water content
• Gastrointestinal motility
• Gastrointestinal lubrication

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Constipation What makes us go
Adapted with permission from Fast Facts and
Concepts 15, EPERC Resource Center.
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Constipating Drugs

• Morphine
• Tricyclic antidepressants
• Scopolamine
• Diphenhydramine
• Vincristine

• Verapamil
• Other Ca channel blockers
• Iron
• Aluminum
• Calcium salts

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Bowel Obstruction...in advanced cancer

• Incidence 3 overall in Hospice
• Ovarian Cancer 5 to 42
• Colorectal Cancer 10 to 30
• Mechanism mechanical, paralytic
• Symptoms...
• Surgery...limited usefulness in terminally ill
  cancer patients

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Management of Bowel Obstruction in Terminally
Ill Patients

• Surgery extremely poor risk
• Aggressive pain management
• Stool softeners, soft / liquid diet
• Manage nausea (Haldol, Benadryl)
• Octreotide

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Octreotide (SandostatinTM)

• Synthetic analogue of Somatostatin
• Decreases intestinal secretion, bile flow
• Increases intestinal absorption
• Adverse effects
• Dry mouth, Flatulence
• Hypo- or hyperglycemia
• Pain at injection site...
• Dosage and administration
• 150 mg SC, bid OR
• 300 mg over 24h by SC infusion. Max. 600 mg/day

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Delirium
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Delirium and terminal agitation

• Delirium up to 85 of terminal cancer patients
• Features may include
• Clouding of consciousness, altered attention
• Perceptual disturbances
• Acute onset, fluctuating course distinguish
  from dementia

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Delirium--Causes

• D Drugs, especially psychotropics
• E Electrolyte imbalance
• L Liver failure
• I Ischemia or hypoxia
• R Renal failure
• I Impaction of stool
• U Urinary tract or other infection
• M Metastases, other neurological

Adapted from Storey, Primer of Palliative Care,
AAHPM.
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Drug Treatment of Delirium

• Haloperidol 1-2 mg PO or SC q1h to calm the
  crisis, then q6-12 hr
• If more sedation is desired, or for the AIDS
  dementia complex, use
• Thioridazine (Mellaril) 25-50 mg PO q1h until
  calm then q6-12 hr OR
• Chlorpromazine 25-50 mg PO or IV until calm then
  q6-12 hr

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Severe Agitated Delirium

• Consider ADDING
• Chlorpromazine (Thorazine) 100 mg q1h PO, PR or
  IV until calm
• Midazolam (Versed) 0.4-4 mg/hr continuous SC or
  IV infusion
• Lorazepam (Ativan) 1-2 mg q1hr until calm (PO, SL
  or IV)

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Dyspnea
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Breathlessness (dyspnea) . . .

• May be described as
• shortness of breath
• a smothering feeling
• inability to get enough air
• suffocation

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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. . . Breathlessness (dyspnea)

• The only reliable measure is patient self-report
• Respiratory rate, pO2, blood gas determinations
  DO NOT correlate with the feeling of
  breathlessness
• Prevalence in the terminally ill 12 74

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Causes of breathlessness

• Anxiety
• Airway obstruction
• Bronchospasm
• Hypoxemia
• Pleural effusion
• Pneumonia
• Pulmonary edema

• Pulmonary embolism
• Thick secretions
• Anemia
• Metabolic
• Family / financial / legal / spiritual /
  practical issues

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Managementof breathlessness

• Treat the underlying cause
• Symptomatic management
• oxygen
• opioids
• anxiolytics
• nonpharmacologic interventions

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Oxygen

• Potent symbol of medical care
• Fan may do just as well
• Expensive
• Pulse oximetry not helpful

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Opioids

• Small doses titrate to get desired relief of
  symptom without side effects
• Relief not related to respiratory rate
• Central and peripheral action

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Anxiolytics

• Safe in combination with opioids
• lorazepam
• 0.5-2 mg po q 1 h prn until settled
• then dose routinely q 46 h to keep settled

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Nonpharmacologic interventions . . .

• Reassure, work to manage anxiety
• Behavioral approaches, eg, relaxation,
  distraction, hypnosis
• Limit the number of people in the room
• Open window

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Nonpharmacologic interventions . . .

• Eliminate environmental irritants
• Keep line of sight clear to outside
• Reduce the room temperature but avoid chilling
  the patient

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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. . . Nonpharmacologic interventions

• Introduce humidity
• Reposition
• elevate the head of the bed
• Sit with arms up on pillow on a table
• Educate, support the family

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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General Approach to Symptom Management at
End-of-Life

• Search for cause of symptom
• History, physical, laboratory (as appropriate)
• Treat underlying cause (if reasonable)
• Treat the symptom
• Re-evaluate frequently

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Questions?
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Resources

• End-of-life Physicians Education Resource Center
  http//www.eperc.mcw.edu
• Education for Physicians on End-of-life Care
  http//www.epec.net

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More ResourcesPalliative Care Consult Service

• Palliative care beeper 8-BEEP, 1809
• Team members
• Nurses Patricia Roberts, Dianne Pannullo
• Social Worker Jeanne Trask
• Chaplain Caroline Silva
• Medical Director Timothy Keay